Commercial Plans

Risk Adjustment Solution for Commercial Health Plans

Improve Your Risk Scores

Reduce your risk of a payment transfer to a competitor plan by ensuring that all properly documented HHS-HCC conditions for your commercial plan population are coded and reported. The HCC Optimizer analyzes every plan member’s medical record using sophisticated text mining to identify properly documented diagnoses in qualified clinical encounter notes. Evidence for each diagnosis that has not been submitted to the edge server can be presented to coders for validation. All documentation for every member is automatically analyzed, eliminating the need for suspect analytics or auditing a sample of your membership.

Eliminate Manual Chart Extraction Costs

Ensure that your Risk Adjustment scores accurately represent the health of your commercial population based on the clinical documentation, not just the claims stream. The HCC Optimizer solution analyzes patient medical records obtained via automated chart extraction, and identifies documents that appear to contain a properly documented risk-adjusting condition. Certified coders then review the evidence for potential risk-adjusting diagnoses that have not been reported previously.

Capture All Properly Documented Diagnoses

Don't only rely on diagnosis codes reported through the claims stream: Go directly to the source of clinical documentation. The HCC Optimizer analyzes every member’s medical record and finds diagnoses documented in qualified face-to-face encounter notes on relevant dates of service. Evidence for each diagnosis is presented to expert coders for validation. The outcome is faster, more accurate coding for 100% of your commercial plan members.

Attain RADV Audit Confidence

The HCC Optimizer increases your RADV audit confidence in three ways. First, all accepted HCC codes can be routed to additional coders or audit supervisors for further review so you can be confident they are properly documented. Second, existing codes from other sources, such as claims and manual chart audit, can be validated with the HCC Optimizer. Improperly documented codes can be deleted. Third, in the event of an HHS RADV audit, the supporting encounter note for every code approved with the HCC Optimizer can be viewed in the HCC Optimizer application at any time.